Sun Life Assurance Company of Canada

Disability Claim Statement – Attending Physician

Instructions
Please complete each section of this form, and then sign and date it and return it to us.

You can submit this form online at www.sunlife.com/us, click on Submit a Disability Claim. Please send the
additional documents by mail or fax:

Mail: Sun Life Assurance Company of Canada, Short-Term Disability Claims, P.O. Box 81915, Wellesley, MA 02481
Fax: 781-304-5599

If complete and accurate information is not provided, we may need to request additional information, which could
delay disability benefits for your patient.
Group policy number
934397

1 | Patient information
Name of patient (first, middle initial, last) M
F
Street Address City State Zip code

Social Security number Date of birth (mm/dd/yyyy)) Phone number

Name of employer (Parent company name)

University of Alabama Health Services Foundation

2 | Diagnosis and history

Please answer as completely as possible. This is important so we can process your patient’s disability benefits quickly. If
we need to follow up with you, your patient’s benefits may be delayed.
Primary Diagnosis (include any complications) ICD-10 Code

Secondary Diagnosis (if applicable) ICD-10 Code

Has patient ever had the same or similar condition? ......................................................................... Yes No
If “Yes,” provide date when condition previously occurred

For a pregnancy, provide the following:

Expected due date (mm/dd/yyyy) Actual delivery date (mm/dd/yyyy)
Delivery type Normal C-Section
List any complications that caused patient to stop working prior to the expected delivery or that would extend the normal
recovery

GDIFM-8645 STD Disability Claim Statement – Attending Physician (STD) 1 of 6 8/19

Claimant: DOB: Policy no.: 934397 CC no:
2 | Diagnosis and history, continued
Is patient’s injury/sickness work related? .................................................................... Yes No Unknown

Diagnostic Testing Performed

Test Date Findings

X-ray

EKG

MRI

PFT

U/S
Other:

3 | Treatment detail
Start date of disability Date of first office visit Date of last office visit Date of next office visit

Was Emergency Room care required for the condition .................................................................... Yes No
Name of hospital Date (mm/dd/yyyy) Phone Number

Check all that apply and describe the type, frequency, and treatment (date and type)

Surgery
Medications prescribed
Therapy
Behavioral intervention
Other
Date from (mm/dd/yyyy) Date to (mm/dd/yyyy)
Hospital Confined
Has patient
House Confined Bed Confined Ambulatory
Hospital Name

4 | Restrictions and limitations

Describe what the patient is unable to do. From
To

Describe what the patient should not do. From

To

GDIFM-8645 STD Disability Claim Statement – Attending Physician (STD) 2 of 6 8/19

Claimant: DOB: Policy no.: 934397 CC no:
4 | Restrictions and limitations, continued
Is patient capable of working with these restrictions/limitations?........................................................ Yes No
Full-time Part-time: hours/day
If capable of part-time, how long will patient be limited to a part-time schedule?

Sun Life believes that Work is Healthy. We seek to maximize your patient’s recovery. Our vocational staff is available to
partner with you in focusing on your patient’s abilities and returning them to wellness and work.

Patient’s dominant hand is: Left Right

Patient is able to use hand for repetitive actions such as:

Simple Grasping Firm Grasping Fine Manipulation Key Boarding
Left Yes No Yes No Yes No Yes No
Right Yes No Yes No Yes No Yes No

In a typical workday, the patient is able to: (This is not considered an FCE)

Continuously Frequently Occasionally Negligible

Walk
Sit
Stand
Bend
Squat
Climb
Twist
Push
Pull
Balance
Kneel
Crawl
Reach above shoulder
Lift ( lbs.)
Carry ( lbs.)
Drive
Left foot pedal
Right foot pedal

Cardiac (if applicable) – Functional Capacity (American Heart Association)

No limitation Marked limitation Slight limitation Complete Limitation

How long will these limitations apply? (estimated)
6-8 weeks 8-12 weeks 12-26 weeks Expected recovery date (mm/dd/yyyy):

GDIFM-8645 STD Disability Claim Statement – Attending Physician (STD) 3 of 6 8/19

Claimant: DOB: Policy no.: 934397 CC no:
4 | Restrictions and limitations, continued
Mental Impairment (if applicable) Current DSM diagnosis

Class 1 – No limitation
Class 2 – Slight limitation
Class 3 – Moderate limitation
Class 4 – Marked limitation
Class 5 – Severe limitation
Do you believe this patient is competent to endorse/direct the use of proceeds? .................................. Yes No

5 | Return-to-work information
Indicate the specific date or recovery period after which the patient will be able to sufficiently perform duties.

Patient can return to his/her part-time occupation in: Date: -or-

1-2 weeks 2-3 weeks 3-4 weeks 5-6 weeks 6-7weeks 7-8weeks
2 months or more Never Other:

Patient can return to his/her full-time occupation in: Date: -or-

1-2 weeks 2-3 weeks 3-4 weeks 5-6 weeks 6-7weeks 7-8weeks
2 months or more Never Other:

6 | Other treating physicians

Name of physician

Specialty Phone number Fax number

Name of physician

Specialty Phone number Fax number

If you need more room, check here and attach a separate sheet.

7 | Certification and signature

I certify that the above statements are true and complete. I have read or had read to me the fraud warning for my state

Name of Attending Physician (first, middle initial, last) Tax ID #

Street address City State Zip code

Specialty Phone Number Fax Number

Attending Physician signature (original signature required) Date signed (mm/dd/yyyy)

X

GDIFM-8645 STD Disability Claim Statement – Attending Physician (STD) 4 of 6 8/19

Claimant: DOB: Policy no.: CC no:
934397
6 | Fraud warnings

General fraud warning: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
AK: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing
false, incomplete, or misleading information may be prosecuted under state law.
AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
AR, LA, MA, MN, RI, TX and WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
AZ: For your protection Arizona law requires the following statement to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal
and civil penalties.
CA: For your protection California law requires the following to appear on this form: Any person who knowingly presents
a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in
state prison.
CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
DC: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
DE, ID and IN: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony.
FL: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an
application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
KS: Any person who knowingly and with intent to defraud any insurance company or other person files an Application for
insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto may be guilty of insurance fraud as determined by a court of law.
KY: Any person who knowingly and with intent to defraud any insurance company or other person files a stat ement of
claim containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime.
MD: Any person who knowingly OR willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly OR willfully presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
ME: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
NH: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud,
as provided in RSA 638:20.
NJ: Any person who knowingly files a statement of claim containing any false or misleading information is subject to
criminal and civil penalties.
NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
OH: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

GDIFM-8645 ST D Disability Claim Statement – Attending Physician (STD) 5 of 6 8/19

Claimant: DOB: Policy no.: 934397 CC no:
6 | Fraud warnings, continued

OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for
the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
OR: Any person who, with intent to defraud or knowingly providing false information may be guilty of fraud and may be
subject to civil or criminal penalties.
PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application,
or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or
presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned
for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be
present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are
present, it may be reduced to a minimum of two (2) years.
TN and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
VA: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement may have violated state law.
VT: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal
offense and subject to penalties under state law.

Contact us

By mail By fax
Sun Life Assurance Company of Canada 781-304-5599
Group Short-Term Disability Claims
P.O. Box 81915
Wellesley Hills, MA 02481

www.sunlife.com/us Customer Service 800-247-6875 M–F 8:00 a.m. – 8:00 p.m., ET

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.
© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved.
Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada.
GDIFM-8645 STD Disability Claim Statement – Attending Physician (STD) 6 of 6 8/19
Claimant: DOB: Policy no.: 934397 CC no: